Lower Extremity MSK Flashcards
What is an Apophysis?
Normal development
- an outgrowth of a bone which arises from a separate ossification center, and fuses to the bone later in development.
Apophysis after forms an important insertion portion for what?
A tendon or ligament
Apophysis is most often mistaken for what?
Fractures
Are fractures generally perpendicular or parallel to diaphysis?
Perpendicular
Are apophysis generally perpendicular or parallel to diaphysis?
Parallel
What are the 2 MC locations for an apophysis?
Knee and Foot
Apophysis usually occurs at what age range?
14-18
How do you distingush a Jones fracture from other foot fractures?
More distal on diaphysis
What is the diaphysis?
- Shaft of long bone
- elongation occurs toward epiphysis
What is the epiphyseal?
- Growth plate
- Site of elongation of long bones
What is the epiphysis?
- Terminal end of long bone
- Ultimately forms articular cartilage
What is a Sesamoid?
A bone that ossifies within a tendon
What is the largest sesamoid in the body?
Patella
Sesamoids are MC found where?
- 1st MTP and 1st MCP
Sesamoid(s) are commonly referred to as what?
- Mouse or Mice
History should include what characteristics?
- Pain
- Mechanical sxs
- Joint effusion
- Mechanism of injury
What is one of the MC causes of knee pain in active adolescents?
Osgood-Schlatter disease
Osgood-Schlatter disease affects what?
Apophasis of proximal tibia
What is the age range and MC gender of Osgood-Schlatter disease?
- 11-15
- M>F (males older at initial presentation)
(bilateral 25-50%)
What is the etiology of Osgood-Schlatter disease?
Micro avulsions caused by repeat reaction on the anterior portion of developing ossification center of the tibial tuberosity
What are S/Sx of Osgood-Schlatter disease?
- Discomfort with resisted knee extension
- stair-walking/climbing and squatting
- pain over tibial tuberosity
Sunrise view/skyline view XR looks at what?
Area under patella
What are the angles of Sunrise view/skyline view XR?
- XR device is at 15 degrees
- Knee is at 115 degrees
What are the general tx options?
- Conservative
- decrease activities
- RICE
- NSAIDs
- PT
- surgery: rarely indicated
- Othro referral: dx uncertain and persistent sxs
Ankle sprains are Mc’ly d/t what?
Inversion during plantar flexion involving lateral ligaments
Are isolated injuries to the medial ligaments common or uncommon and involve what?
- Uncommon
- Involve a medial malleolar fracture
Thomsons test is used to assess Achilles rupture but can be misleading, why?
- Partial tear may be present which means ankle can still move slightly
A high index of a talar dome fx is warranted when the pt presents with what sxs?
Chronic swelling and/or locking of ankles 4-5 wks post-injury
Do kids often sprain a joint?
NO- they fracture
Is fibular a weight bearing bone?
No- not weight bearing
A buckle or torus fracture is often d/t what?
FOOSH
An open growth plate is indicative of what?
A younger pt
What is a sprain?
Stretch and/or tear of a ligament
Ligaments connect what?
Fibrous bands of connective tissue that connect bone to bone
What is a strain?
Injury of a muscle and/or tendon
Tendons connect what?
Fibrous structures attaching muscles to bone
High ankle sprain often involves what?
Soft tissue ligament tears not seen on XR
What are the lateral ligaments?
- Anterior talofibular ligament (ATL)
- Calceneoufibular ligement (CL)
- Posterior talofibular ligament (PTL)
What is the medial ligaments?
Deltoid ligament
The pt will often hear what when they fracture of fifth metatarsal?
Hear a pop
What are some special maneuvers for ankle injuries?
- Anterior drawer test
- Tilt test
- Thompson test
Osteomyelitis is commonly seen in what?
Open injuries or recent surgeries
Reiters is often caused by what?
STD- Chlamydia
What are the specific sites for traumatic fractures?
- Calcaneal
- Tibia
- Fibular
- Metatarsal
- Tarsals
What are some common traumatic fractures?
- Stress Fx
- Avulsion Fx
- Interosseous Fx
A mortise view is used to identify what?
Uniformities in talar dome (able to see dislocation better)
What are the routine ankle views?
- Lateral
- AP
- Mortise
What are the routine foot views?
- AP
- Oblique
- Lateral
Lateral malleolus fracture involves what bone?
Distal Fibula
Medial malleolus fracture involves what bone?
Distal Tibia
Posterior malleolus fracture involves what bone?
Posterior prominence of Tibia
Bimalleolar fractures involve what bones?
- Both distal Tibia and Fibula
- Unstable ankle fx’s
Trimalleolar fractures involve what bones?
- Three fx involving both Tibia and Fibula
- Unstable ankle fx’s
What are some signs of Trimalleolar fractures?
Cold to the touch, no cap refill, and decreases pulses.
A fifth metatarsal fx is usually located where?
The base of 5th MT
Lisfrancs fx is located where and usually caused by what?
- Mid-Foot fx
- Kickball or kicking walls
Syndesmotic injury are also called what?
High ankle sprain
Syndesmotic injury are usually a result of what?
Ankle eversion and step and twist
Syndesmotic injury involves ligaments attaching to what?
Ligaments attaching distal tibia and fibula
Syndesmotic injury may or may not be associated with what?
Actual fracture, but is treated as a fracture
On an XR of a Syndesmotic injury what is often seen?
Widening between fibular and tibula
On an XR for a Lisfranc fx what is often seen?
- Bones are pushed sideways and displaced laterally
- widening between big toe and 2nd toe
What is a type 1 injury?
Ligament stretched or minor tear
When can someone return to play with a type 1 injury?
1-10 days
What is a type 2 injury?
Partial ligament tear
When can someone return to play with a type 2 injury?
2-4 wks
What is a type 3 injury?
Complete ligament tear
When can someone return to play with a type 3 injury?
5-8 wks (ortho call is needed)
What is a do not miss diagnosis in adolescents with hip pain?
Slipped capital femoral epiphysis: d/t risk for AVN
What are historical findings of Trochanteric Bursitis?
- Single blow or friction from IT band.
- Predisposing factor: hx of training changes or increased Q angle.
- MC bursitis.
- “snapping hip” syndrome
What are PE findings for Trochanteric Bursitis?
- Pain to lateral aspect of the hip that is made worse w/ direct pressure over the bursa.
- Well localized.
What is the largest sesamoid bone in the human body?
Patella w/ quadriceps tendon
What does PRICE stand for?
P: protect the joint R: Rest I: Ice C: Compression E: Elevate
AP view of the knee is helpful in diagnosing what?
- Arthritis in the knee joint between the thigh and shin bones.
- It can also show whether there is arthritis in the inside or outside of the knee
Lateral view of the knee is helpful in diagnosing what?
Most useful for diagnosing arthritis between the kneecap and the thigh bone.
Skyline view of the knee is helpful in diagnosing what?
Looks between the kneecap and helpful for diagnosing arthritis
What are the radiologic characteristics of a Jones fracture?
Transverse orientation, involves the inter-metatarsal articulation
- Fracture of the proximal diaphysis of the 5th metatarsal
What are the radiologic characteristics of a 5th metatarsal fx?
Transverse or oblique orientation, shaft of the bone-distal to inter-metatarsal joint,
What structures are involved in a Lisfranc injury?
Midfoot and tarsometatarsal joint
What are the 3 common Lisfranc injury patterns?
- Homolateral
- Isolated
- Divergent
Homolateral (Lisfranc injruy) involves what structures?
All 5 MT (or 2-5)
- displaces laterally
Isolated (Lisfranc injruy) involves what structures?
1 or 2 MT displaced
Divergent (Lisfranc injruy) involves what structures?
-2-5 displaced laterally while the 1st MT is displaced medically
What is the workup for a Lisfranc injury?
- FWB: XR w/ comparison view = CRITICAL
- If XR normal but high suspicion: MRI or CT
What are the 6 Ps for compartment syndrome?
- Pain
- Pallor
- Paresthesia
- Paralysis
- Pulslessness
- Pain out of proportion
What are the clinical findings of compartment syndrome?
Increased pressure in closed muscle compartment
- 3 compartments in thigh
- 4 in lower leg
What is the tx for compartment syndrome?
- Orthopedic emergency (>40 mmHg)
- Surgical fasciotomy within 4-6 hrs
What causes Slipped capital femoral epiphysis?
- Weakened epiphyseal plate of femur
- displaced femoral head
What is the classic patient of Slipped capital femoral epiphysis?
- Male
- 10-16
- Obese
What is the workup for Slipped capital femoral epiphysis?
Frog leg lateral pelvis or lateral hip view
What is the treatment for Slipped capital femoral epiphysis?
Pinning and non weight bearing
What are some risk factors for nonunion?
- Fracture stability
- Blood supply (inherent soft tissue damage, smoking, DM, vascular disease)
- Nutrition
AVN of the femoral head is also known as what?
“Leg Calve Perthes” in children
What are S/Sxs of Leg Calve Perthes?
Dull ache and limp (x3-6 wks)
- aching pain in groin or proximal thigh
What is seen on the hip XR in a pt with Leg Calve Perthes?
Crescent sign - resembles a subchondral fracture
What is the tx for Leg Calve Perthes?
- Long leg casts with spreader par (petrie casts) x 6 wks
- surgical: osteotomy
When do strains occur?
Occur secondary to dynamic overload during eccentric muscle contraction
What are the 2 types of hip fractures?
Intracapsular and Extracapsular
Intracapsular hip fractures involved what structures?
Femoral head and neck
Extracapsular hip fractures involved what structures?
Intertrochanteric/subtrochanteric
What are characteristics of Intracapsular hip fractures?
- Higher rates of nonunion, malunion, AVN
- Common in older adults
- Occurs 1-2 inches from joint
- Risk to blood supply
What are characteristics of extracapsular hip fractures?
- Occurs 3-5 inches from joint
- Does not interrupt blood supply
What are the weber classifications of a fibular fracture?
- A: below syndesmosis
- B: level of syndesmosis
- C: above level of syndesmosis
Hip fractures are more common in who?
- Women > men
- White females > black or Hispanic females
What are some causes of a hip fracture?
Falls
- Direct blow
- Osteoporosis (stand and twist)
How will a pt with a hip dislocation be laying?
- Leg internally rotated and adduction
How will a pt with a hip fracture be laying?
- Leg externally rotated and abduction
Is a hip dislocation a medical emergency or no?
- Medical emergency
- very rare
What are PE findings of a hip disclocation?
- Limp when walking
- Shortening of leg
- AROM is impossible
- No attempt to reduce to prevent affecting vasculature, sensory and vascular check
What is Piriformis syndrome?
Impingement of the sciatic nerve from spasm of piriformis muscles
- 6x more common in women
In Piriformis syndrome where does the sciatic nerve pass under?
- Passes under or through the piriformis muslces
Piriformis syndrome mimics what?
Lumbar nerve root impairment and intervertebral disk disease
What are the causes of Degenerative hip changes?
- Age
- Repetitive trauma
- Acute trauma
- Improper arrangement of hip
What are the risks for Degenerative hip changes?
- Degeneration of articular surfaces of femur or acetabulum
- Arthritis
- Osteochondrosis dissecans
- Acetabular labrum tears
- AVN
What are S/Sx of Degenerative hip changes?
- Pain
- Referred to low back
- Anterior thigh
- Knee LOM in all planes
- Decreased strength
What are S/Sx of Ischial tuberosity bursitis?
- Movement of buttocks while pt is weight bearing in seated position can irritate the bursa
- Irritated by prolonged sitting
What do you need to r/o before diagnosing Ischial tuberosity bursitis?
R/o hamstring strain or avulsion of its attachment
